CT SB00258

Utilization review companies must provide enrollees with copies of all enrollee-specific documents and information considered in final determinations not to certify, upon request, within five business days by electronic mail, facsimile, or other expeditious method.

Final determination notices must include a statement that the utilization review company will provide requested documents and information, in addition to principal reasons for denial, exhaustion of internal appeals, and commissioner appeal procedures.

Providers of record and enrollees may both appeal determinations not to certify; appeals by providers are deemed made on behalf of and with consent of enrollees if services have not been provided or if denial creates financial liability to the enrollee.

All utilization review determinations must be made by licensed health professionals, with final determinations for Connecticut enrollees requiring a physician, nurse, or other licensed health professional with a current Connecticut license from the Department of Public Health.

Amendments become effective October 1, 2010 and apply to utilization review determinations made by preferred provider networks and managed care organizations.